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View from the Other Side of the Stethoscope: Metaphor as Medicine

I suffer from a disease like Tourettes. Only instead of grunts or coprolalia, my phonic utterances are analogies and metaphors. And instead of being erratic, their appearance is predictable, peppering my explanations whenever a listener looks the least bit confused or doubting.

As a practicing internist, I used metaphors all the time, embracing my quirk as a gift that helped me teach, motivate, and comfort. When patients quickly understood my message or at follow-up visits used one of my metaphors, my heart soared.

By tapping into my patients' knowledge of familiar things, metaphors transmitted new information in a minimum of time. And if there was something I didn't have much of in my office, it was time.

Only after developing cancer did I stop to reflect on my linguistic tic. And what I've come to realize is that I wish medical schools would devote a few minutes of class time to a discussion of medical metaphors.

In the setting of clinician-patient communications, metaphors are more than ear candy to make speech entertaining or elegant, like trick candles or sugar flowers atop a cake. Clinicians' metaphors communicate key messages, like the loopy letters spelling “Happy Birthday.” They help simplify complex ideas, normalize what feels foreign to patients, calm patients' fears, bolster patients' confidence, and motivate patients to action.

Where I'd fallen short in my medical practice was recognizing the potential dangers of metaphors. Comparing tumor growth to a stuck brake pedal may be an efficient way to explain the dysregulation of cell reproduction, but the literary shortcut risks terrorizing some patients with images of a runaway car crashing into a tree.

I also wish I'd been more selective when using metaphors that portray symptoms and illnesses as purely mechanistic problems. It's not that comparing atherosclerotic vessels to clogged pipes isn't helpful. My concern is that such metaphors can unwittingly steer patients to see their physicians as repair technicians rather than as healers caring about their illness in the context of their life.

Unquestionably, metaphors, similes, analogies, and other twists of language have shaped my perspective about life on the other side of the stethoscope. Between office visits, war imagery bombarded me incessantly from all fronts—friends, magazines, the news media. But I didn't like “battling” anything. I felt alienated. My internist sensed this and offered a gentler image to help me manage expectations and feel whole: We talked of weeds (recurrences) as problems that demanded attention but didn't keep me from having a beautiful garden (life).

What's clear is that we all think in metaphors. We feel in metaphors. So if I were given a few minutes to address medical students, this is what I'd say:

* Listen to your patients' metaphors. Patients' personification of cancer (such as “the Beast”) and their descriptors of destruction (such as “nuking my brain”) reflect patients' fears and anxieties as well as their sense of vulnerability, helplessness, guilt and even revulsion.

* Acknowledge patients' metaphors. Thank patients for metaphors that help you understand. Consciously use their helpful metaphors in your responses. Doing so reassures patients they are being heard (e.g., “How is that feeling of ‘being in a fog’ you described at your last visit doing now?”).

* Ask about ambiguous metaphors. For example, ask them to tell you what they mean when they say their cancer is like roaches. Patients' answers may reveal continued hope for a cure (“We'll just knock out these few that slipped through”), acceptance (“I'll be dealing with them periodically from now on”), or despair (“It's impossible to get rid of them”).

* Avoid metaphors that can be frightening, demeaning, or suggestive of blaming the patient. Lymph nodes are “protective filters,” not “garbage dumps.” Scan results are “normal,” not “clean,” otherwise you are implying that abnormal scans are “dirty.” And if your patient's disease progresses despite treatment, remember this: The “treatment failed” your patient, and not the other way around.

* Offer patients a variety of metaphors. Maybe one will resonate with a healing pitch. If patients' metaphors have inappropriately negative connotations, offer them alternatives. Then give patients the freedom to accept or reject your offerings. For example, “You tell me you feel like ‘a fish out of water, thrashing uselessly.’ I see you as being more like a cat: You flail when facing new challenges, but you always land on your feet.” In this latter example, the unspoken notion of nine lives can be healing, too.

* Use metaphors that empower patients and leave room for hope. Images of races, games, performances, or contests can help you highlight the possibility of a good outcome. If caring for patients with terminal disease, you can focus on the belief that what matters most is “how you play the game.” If using the metaphor of a marathon to guide patients through prolonged ordeals, you can focus on the value of preparing and then pacing oneself. You can encourage patients to keep going despite setbacks or running out of steam on the final laps.

* When in doubt, don't. Metaphors provide a convenient way to sidestep difficult truths when the news is not good. Resist the temptation, because these are times when patients need the facts couched not in a metaphor but in a compassionate tone of voice and touch of your hand.

In the end, it matters less what clinicians say than what their patients hear. In the care of patients, keep in mind that metaphors, like medicines, have the power to heal or to harm. So choose your metaphors wisely. Tailor them to each individual patient. And enjoy the uniquely human gift of using words to help another heal.